Current through Reg. 50, No. 13; March 28, 2025
(a) For an out-of-network claim for which the
insured is protected from balance billing under Insurance Code Chapter 1301,
concerning Preferred Provider Benefit Plans, or when no preferred provider is
reasonably available, an insurer must pay the claim at the preferred level of
coverage, including with respect to any applicable copay, coinsurance,
deductible, or maximum out-of-pocket amount. The insurer must pay the claim
according to the following payment standards:
(1) for emergency care and post-emergency
stabilization care, the applicable payment standards are under §1301.0053,
concerning Exclusive Provider Benefit Plans: Emergency Care; and
§1301.155, concerning Emergency Care;
(2) for certain care provided in a health
care facility, the applicable payment standards are under §1301.164,
concerning Out-of-Network Facility-Based Providers;
(3) for certain diagnostic imaging or
laboratory services performed in connection with care provided by a preferred
provider, the applicable payment standards are under §1301.165, concerning
Out-of-Network Diagnostic Imaging Provider or Laboratory Service
Provider;
(4) until August 31,
2025, for certain services and transports provided by an emergency medical
services provider, other than air ambulance, the applicable payment standards
are under §1301.166, concerning Out-of-Network Emergency Medical Services
Provider; and
(5) for services
provided by a nonpreferred provider when a preferred provider is not available
within the network adequacy standards established in §
3.3704(f) of
this title (relating to Freedom of Choice; Availability of Preferred
Providers), the applicable payment standards are under Insurance Code §
1301.005, concerning
Availability of Preferred Providers; Service Area Limitations, and Insurance
Code §
1301.0052, concerning
Exclusive Provider Benefit Plans: Referrals for Medically Necessary
Services.
(b) If
medically necessary covered services are not available through a preferred
provider within the network adequacy standards under §
3.3704(f) of
this title (relating to Network Requirements) and the services are not subject
to subsection (a)(1) - (4) of this section, the insurer must:
(1) for a preferred or exclusive provider
benefit plan:
(A) facilitate the insured's
access to care consistent with the access plan and documented plan procedures
specified in §
3.3707(j) of
this title (relating to Waiver Due to Failure to Contract in Local Markets);
and
(B) inform the insured that:
(i) the out-of-network care the insured
receives for the identified services will be covered under the preferred level
of coverage with respect to any applicable cost-sharing and will not be subject
to any service area limitation;
(ii) the insured can choose to use a
physician or provider recommended by the insurer without being responsible for
an amount in excess of the cost sharing under the plan, or an alternative
nonpreferred provider chosen by the insured, with the understanding that the
insured will be responsible for any balance bill amount the alternative
nonpreferred provider may charge in excess of the insurer's reimbursement rate;
and
(iii) the amount the insurer
will reimburse for the anticipated services.
(2) for an exclusive provider plan:
(A) process a referral to a nonpreferred
provider within the time appropriate to the circumstances relating to the
delivery of the services and the condition of the patient, but in no event to
exceed five business days after receipt of reasonably requested documentation;
and
(B) provide for a review by a
physician or provider with expertise in the same specialty as or a specialty
similar to the type of physician or provider to whom a referral is requested
under subparagraph (A) of this paragraph before the insurer may deny the
referral.
(c)
Reimbursements of all nonpreferred providers for services that are covered
under the health insurance policy are required to be calculated pursuant to an
appropriate methodology that:
(1) if based on
claims data, is based upon sufficient data to constitute a representative and
statistically valid sample;
(2) is
updated no less than once per year;
(3) does not use data that is more than three
years old; and
(4) is consistent
with nationally recognized and generally accepted bundling edits and
logic.
(d) Except for an
exclusive provider benefit plan, an insurer is required to pay all covered
out-of-network benefits for services obtained from health care providers or
physicians at least at the plan's out-of-network benefit level of coverage,
regardless of whether the service is provided within the designated service
area for the plan. Provision of services by health care providers or physicians
outside the designated service area for the plan must not be a basis for denial
of a claim.
(e) Consistent with
Insurance Code §
1301.140, concerning
Out-of-Pocket Expense Credit, an insurer must establish a procedure by which an
insured may:
(1) identify the average
discounted rate paid by the insurer to a given type of preferred provider for a
covered service or supply;
(2)
obtain a covered service or supply; and
(3) claim a credit, under the preferred level
of coverage, toward the insured's deductible and annual maximum out-of-pocket
amount, for the amount paid by the insured, if:
(A) the amount the insured paid is less than
the insurer's average discounted rate;
(B) the insurer has not paid a claim for the
service or supply; and
(C) the
insured submits the documentation identified by the insurer, according to the
process set forth on the insurer's website and in the insured's certificate of
insurance.
(f)
An insurer must cover a clinician-administered drug under the preferred level
of coverage if it meets the criteria under Insurance Code Chapter 1369,
Subchapter Q, concerning Clinician-Administered Drugs.
